Consumer Credit Counseling Services of Coos-Curry Inc.

You may complete this form on the screen and then print it;
or, print it first and complete it in ink.

Please fill out the form completely. Make an extra copy to keep for your records.

GENERAL INFORMATION FORM
1. Last Name
First Name
Middle/Maiden

Single, Married, Widowed, Divorced, Separated
# of Dependants Rent or Own Home

Birth Date Social Security

Address City, State, Zip

Residential Phone Cell Phone

Income Per Month

Gross Pay, Monthly Take Home Pay, Monthly

Weekly Biweekly Semimonthly Monthly

Deductions from pay (other than taxes; e.g. insurance/savings) $

Employer Position

How long employed? Telephone

Other Income/Source

2. Co-Applicant Last Name

First Name
Middle/Maiden

Birth Date Social Security

Address City, State, Zip

Residential Phone Cell Phone

Income Per Month

Co-Applicant Gross Pay, Monthly
Take Home Pay, Monthly

Weekly Biweekly Semimonthly Monthly

Deductions from pay (other than taxes; e.g. insurance/savings) $

Employer Position

How long employed? Telephone

Other Income/Source

IMPORTANT NOTICE: READ BEFORE SIGNING

Consumer Credit Counseling Service (CCCS) offers a variety of programs to address the resolution of credit problems. COMPLETION OF THIS WORKSHEET DOES NOT AUTOMATICALLY GUARANTEE PARTICIPATION IN A DEBT MANAGEMENT PROGRAM. Another option or resource may better suit your needs.

CCCS does not report participation in a DEBT MANAGEMENT PROGRAM TO CREDIT REPORTING AGENCIES. CCCS has no control over the credit reporting practices of your creditors. Your involvement in a program may ADVERSELY affect your CREDIT REPORT.

CLIENT STATEMENT

Everything that has been stated in this worksheet is complete and correct to the best of my knowledge. I agree to hold Consumer Credit Counseling Service, its employees, officers and agents harmless from any claim, suit, action or demand of my creditors, myself, or any other persons as a result of this counseling.

Signature

Signature

Financial Records

Assets

Real Estate Property/House	Rental Property
Automobiles	Recreation Vehicle
Boat/ATV	Motorcycle
Stocks/Bonds	Savings Account
Other
Total Assets

Monthly Living Expenses (Some of these expenses may not apply to you, so just put a zero (0) in the box for those that don't apply. Please add a note of explanation for extenuating circumstances that require an excess amount for any particular category. Thank you.)

Rent/Storage
First Mortgage
Second Mortgage
Property Taxes
Gasoline
Auto Maintenance
Auto Registration
Groceries
Meals Out
Food at Work
School Lunches
Electric/gas/oil/propane/wood
Water/Sewer
Telephone
Garbage/Recycling
Pager/Cellular Phone
Internet Service
Cable TV/Satellite
Family clothing
Auto Insurance
Medical Insurance
Life Insurance
Home/Renters Insurance
Prescriptions
Doctor Visits
Optical
Daycare
Diapers
Child Support
Car Payment
Student Loans
State/Federal Taxes
Other Loans
Tithe
Other Charity
Books/Newspapers/Magazines
Entertainment/Recreation
Gifts/Holidays
Alcohol/Tobacco
Tools for Work
Special Work Clothing
Other Work Expense
Dry Cleaning/Laundry
Home Maintenance
Home Cleaning Supplies
Personal Care
Postage
Bank Charges
Pet Care/Food
Other Miscellaneous

Total Monthly Living Expenses

List of all Debts (print off additional pages if necessary)

Creditor
Address
City, State, Zip
Phone Number
Account Number
Account Description
Balance
Monthly Payment
Due Date Interest Rate

Creditor
Address
City, State, Zip
Phone Number
Account Number
Account Description
Balance
Monthly Payment
Due Date Interest Rate

Creditor
Address
City, State, Zip
Phone Number
Account Number
Account Description
Balance
Monthly Payment
Due Date Interest Rate

Creditor
Address
City, State, Zip
Phone Number
Account Number
Account Description
Balance
Monthly Payment
Due Date Interest Rate

Creditor
Address
City, State, Zip
Phone Number
Account Number
Account Description
Balance
Monthly Payment
Due Date Interest Rate

Creditor
Address
City, State, Zip
Phone Number
Account Number
Account Description
Balance
Monthly Payment
Due Date Interest Rate

Creditor
Address
City, State, Zip
Phone Number
Account Number
Account Description
Balance
Monthly Payment
Due Date Interest Rate

Creditor
Address
City, State, Zip
Phone Number
Account Number
Account Description
Balance
Monthly Payment
Due Date Interest Rate

Creditor
Address
City, State, Zip
Phone Number
Account Number
Account Description
Balance
Monthly Payment
Due Date Interest Rate

Creditor
Address
City, State, Zip
Phone Number
Account Number
Account Description
Balance
Monthly Payment
Due Date Interest Rate

Creditor
Address
City, State, Zip
Phone Number
Account Number
Account Description
Balance
Monthly Payment
Due Date Interest Rate